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<meta name="description" content="新的一个课题了，唐红柳老师讲的。第一节 临床与“肉”的协调减：冠延长术。加：游离龈移植,附着龈加宽术，种植中用得多。在天然牙中：根面覆盖术。第二节 牙周根面覆盖术的适应症牙周根面覆盖术的适应症：a.牙龈退缩引发的美观问题。b.牙根面牙本质敏感症。c.角化龈缺失相关的口腔卫生维护困难。第三节 牙龈退缩Miller分类是基于牙龈退缩区域邻近的邻面骨高度以及牙龈缘与膜龈联合的位置关系。膜龈联合：牙龈可动">
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        <p><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B0%5D.png"><br>新的一个课题了，唐红柳老师讲的。<br>第一节 临床与“肉”的协调<br>减：冠延长术。<br>加：游离龈移植,附着龈加宽术，种植中用得多。在天然牙中：根面覆盖术。<br>第二节 牙周根面覆盖术的适应症<br>牙周根面覆盖术的适应症：<br>a.牙龈退缩引发的美观问题。<br>b.牙根面牙本质敏感症。<br>c.角化龈缺失相关的口腔卫生维护困难。<br>第三节 牙龈退缩Miller分类<br>是基于牙龈退缩区域邻近的邻面骨高度以及牙龈缘与膜龈联合的位置关系。<br>膜龈联合：牙龈可动与不可动部分的交界。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B1%5D.png"><br>术前：<br>医患沟通（降低患者期望值）、几分类、能否确定CEJ。<br>第四节 根面处理：机械与化学<br>根面平整的目的在于去除微生物的沉积及软化脱矿的牙根组织（牙骨质及牙本质），提供光滑坚硬的表面，利于软组织的附着。<br>A、机械处理<br>指根面平整术。<br>翻瓣前还是翻瓣后？<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B2%5D.png"><br>区分病理性及解剖性骨开裂，根据CAL测量。CAL到根方骨嵴顶之间的骨开裂为解剖性的，不能进行根面平整。<br>翻瓣前处理：有利于保持骨开裂区域根面牙骨质的完整，并在无出血的情况下完成。刮治器可导致软组织损伤，尤其在牙龈退缩伴有颊侧牙周袋时，且增加了颊侧袋内根面平整的不知风险，从而可能导致遗留已感染的，软化的根面，进而影响根面覆盖手术的效果或增加探诊深度。<br>翻瓣后：避免了软组织损伤而更容易操作，且能更彻底平整临床附着丧失区域的根面。存在刮去尚有纤维附着的健康牙骨质的风险，尤其是骨开裂区域内的结缔组织纤维。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B3%5D.png"><br>术前平整：推荐颊侧龈沟较浅（小于1mm）且暴露根面根方角化组织较宽（大于3mm），同时也适用于暴露根面根方剩余软组织不用于根面覆盖时。<br>术中平整：适用于除了上述情况外的所有病历，常用于伴有龋或脱矿根面的牙龈退缩病历。<br>术前已有树脂充填该如何处理根面？去除充填体，牙龈需要的是牙骨质，而不是树脂。<br>B.化学处理：<br>指利用酸性物质对根面进行处理。<br>常用药物为24%的EDTA。<br>原理：去除根面平整后沉积于牙本质小管内的表面玷污层，暴露牙本质小管内的胶原纤维，从而使其与根面和软组织的血凝块中的胶原蛋白网相互作用。<br>使用方法：刮治后清除牙根表面的碎屑及血迹，并使用EDTA凝胶处理2分钟，随后采用无菌生理盐水冲洗至少1分钟。<br>酸性物质（枸橼酸、四环素）根面处理<br>目的：扩大牙本质小管的直径使胶原纤维暴露，从而利于纤维蛋白凝块黏附。<br>疑点：酸性物质可活化基质金属蛋白酶，导致小管内胶原降解，从而去除了纤维凝块与根面的相互作用的基质根面表层。<br>C、釉原蛋白在膜龈手术中的运用<br>模仿牙根发育过程。<br>来源：从猪牙胚中提取的釉基质衍生物（EMD）<br>原理：根面蛋白的吸引，凝块中的细胞转化为牙本质细胞、成纤维细胞以及成骨细胞、再生部的牙周组织。<br>使用方法：EDTA处理2min后，应用EMD作用于根面，根面需保持无血和无唾液的污染，以保蛋白的沉积，时间2min。<br>第五节 根面覆盖术术式的分类<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B4%5D.png"><br>附加松弛切口冠向复位瓣<br>隧道复位瓣<br>FGG<br>侧向转位冠向复位瓣<br>第六节 附加松弛切口冠向复位瓣<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B5%5D.png"><br>任何手术都要做术前计划。<br>先明确CAL。<br>判断Miller分类。<br>预判手术效果。<br>计算要取的软组织的量。理想的软组织要盖住CEJ1-2mm。长度：3（近中）+4（暴露的CEJ的近远中距离）+3（远中）= 10mm。宽度：3+3 = 6mm。3是健康牙龈覆盖。<br>切口设计：牙龈退缩3mm，切口离开龈乳头3mm+1mm。从CEJ向近远中延伸，距邻牙龈缘至少1mm，向根方做垂直附加切口，超过膜龈联合。采取半厚瓣。不用剥离器，用刀片剥离。F为生理性骨开裂位置，可以采用全厚瓣。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B6%5D.png"><br>受区准备<br>保证移植组织的充足血供<br>为移植组织提供坚固固定<br>表面预备规整，使移植组织能紧密贴合<br>获得止血<br>第七节 结缔组织摘取方式<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B7%5D.png"><br>供区预备：<br>第一前磨牙远中-第一磨牙的近中腭侧光滑面<br>缺牙区的牙槽嵴表面<br>上颌结节<br>上皮腭侧软组织移植术<br>上腭粘膜移植组织厚度根据上颌第一磨牙区横断面分类<br>全厚（1.25-1.75mm）：含上皮和所有固有层。<br>非全厚（0.75-1.25mm）：依据固有层厚度分厚、中、薄<br>移植组织不能带有脂肪或腺体组织。<br>15C刀片刃厚度1.0mm，长10mm<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B8%5D.png"><br>带上皮结缔组织移植：供区手术，双切口技术<br>15C刀片距离相邻前磨牙龈缘2-3mm处做全厚曲线切口，切口应限于4的远中-6的近中。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B9%5D.png"><br>切口应达到15C刀片斜面深度（1.0mm），该切口深度决定了可以获取的供体组织厚度。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B10%5D.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B11%5D.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B12%5D.png"><br>取下的组织要放到提前准备好的盐水纱布上，并用盐水纱布对创面进行压迫。<br>去除取下的组织上的上皮，腺体等，只剩结缔组织。<br>去上皮结缔组织移植<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B13%5D.png"><br>难度比上一种术式大。术后反应较轻。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B14%5D.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B15%5D.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B16%5D.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B17%5D.png"><br>腭侧创面用明胶海绵缝合固定。<br>为移植组织提供坚固固定<br>在最初愈合阶段，移植物的活动性会妨碍其早期营养或中断移植物形成的循环供应，导致移植组织特别脆弱甚至坏死脱落。<br>同种异体去细胞真皮<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B18%5D.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B19%5D.png"><br>完整手术流程<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B20%5D.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B21%5D.png"><br>第八节 隧道术联合结缔组织冠向复位瓣<br>没有附加切口，需要手术套装。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B22%5D.png"><br>在健康牙龈上做。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B23%5D.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B24%5D.png"><br>牙龈颜色有差异，用在非美学区。<br>组织生长存在方式<br>牙根冠方约50%的长结合上皮，根面根方约50%的新结缔组织附着。<br>手术难点在腭侧结缔组织的获取，练习，用橘子皮。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B25%5D.png"><br>荐书<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0152-2019rdh/034/Image%20%5B26%5D.png"><br>就当了解一下吧。</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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